Oregon s Health System Transformation: The Coordinated Care Model. March 2014 Jeanene Smith MD, MPH Chief Medical Officer- Oregon Health Authority

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1 Oregon s Health System Transformation: The Coordinated Care Model March 2014 Jeanene Smith MD, MPH Chief Medical Officer- Oregon Health Authority

2 The Challenges Oregon Faced Rising healthcare costs outpacing state budget in Oregon Health Plan (Medicaid) and in state employees benefits 85 percent of Oregon Health Plan clients were managed in silos: 16 managed physical health care organizations 10 mental health organizations 8 dental care organizations. Traditional vendor relationships with health plans in both Medicaid and State Employees, without directed accountability nor incentives to be innovative. Only a few alternative payment reform efforts by some payers and a few patient centered medical home pilot efforts 2 Smith

3 Oregon Chose a New Way Better health, Better Care & Lower Costs Governor s Vision Transform the Delivery System Robust public process Bi partisan support Federal waiver approved $1.9B investment tied to quality and reduction in costs New coordinated care model starting in Medicaid, aiming to spread to other state purchased coverage, and into Oregon s Health Insurance Exchange, private payers

4 Smith Coordinated Care Organizations

5 Key Levers for Transforming Health Care Delivery

6 Oregon s Commitments to CMS Cost and Quality Accountability Plan: Reduce the annual increase in the cost of care (the cost curve) by 2 percentage points Ensure that quality of care improves Ensure that population health improves Establish a 1% withhold for timely and accurate reporting of data Establish a quality pool

7 State Test for Quality and Access Annual assessment of Oregon s statewide performance on 33 metrics, in 7 quality improvement focus areas: Improving behavioral and physical health coordination Improving perinatal and maternity care Reducing preventable re hospitalizations Ensuring appropriate care is delivered in appropriate settings Improving primary care for all populations Reducing preventable and unnecessarily costly utilization by super users Addressing discrete health issues (such as asthma, diabetes, hypertension) Significant penalties if goals not achieved

8 CCO Quality Incentive Pool: How it works CCOs Incentive Pool based on 17 of the 33 metrics Phase 1: Distribution by meeting improvement or performance target, with a minimum floor for all CCOs Phase 2: Challenge pool (remainder) distributed based on 4 metrics: PCPCH enrollment Screening for depression and follow up plan Use of SBIRT tool for substance abuse Optimal diabetes care

9 Quality Strategy Includes Supports for Transformation Transformation Center and Innovator Agents Learning Collaboratives, Technical Assistance Peer to peer and rapid cycle learning systems Community Advisory Councils: Community health assessments and improvement plan Non traditional healthcare workers Primary care home adoption Plus: Recent additional funding from Oregon Legislature for investment in Transformation and Innovation efforts across CCOs

10 Meeting the triple aim: what we are seeing so far CCOs serve over 90 % of Oregon s Medicaid population Every CCO is living within their global budget. The state is meeting its commitment to reduce Medicaid spending trend on a per person basis by 2 percentage points. State level progress on measures of quality, utilization, and cost (for the first 9 months of 2013) show promising signs of improvements in quality and cost and a shifting of resources to primary care. Progress may not be linear but data are encouraging.

11 Progress data show Decreased emergency department visits and expenditures Increased use of developmental screening in the first 36 months of life Increased primary care visits and expenditures Increased enrollment in patient centered primary care homes Increased adoption of electronic health records Decreased hospitalization for congestive heart failure, chronic obstructive pulmonary disease and adult asthma Decreased all cause hospital readmissions

12 What progress data indicate Emergency department (ED) utilization is down. First nine months indicate that ED utilization is down 13% from rate in Ambulatory Care: ED utilization Rate of patient visits to the ED per 1,000 member months Benchmark Baseline Lower is better 2013 (Jan Sept) Benchmark: 2012 national Medicaid 90 th percentile

13 What progress data indicate CCO primary care visits are up nearly 16% from 2011 baseline. Ambulatory Care: Primary care medical visits (includes immunizations/injections) Rate primary care visits per 1,000 members

14 What progress data indicate Change CCO primary care costs are up over 18% from 2011 baseline. CCO primary care cost per member per month (pmpm)

15 What progress data indicate All cause readmissions are currently down by 8%. Percentage of adults who had a hospital stay and were readmitted for any reason within 30 days of discharge.

16 What progress data indicate Potentially avoidable hospitalizations for chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and adult asthma are currently down.

17 How we are moving forward Health Reform 2.0 Changing care model to bend the cost curve and improve health. Proof of concept in Medicaid, aim to extend the care model across populations Align purchasing of care model: begin with Oregon Health Plan, extend to other state purchasing and then align with private sector purchasing. State employees benefit board s RFP in progress, with expectations successful bidders will be held accountable for key elements of coordinated care model.

18 Just some of the current and future challenges we are working to address Change is hard Change is very hard Time, resources and expectations No time, limited resources and large expectations Operating in both an old and new paradigm

19 Some additional challenges we are working to address Increasing consumer engagement and personal responsibility for health Training and using new health care workers Health information exchange Robustly transforming care and paying for outcomes Accounting for flexible services Integrating dental care; increased behavioral health integration Ensuring robust provider networks to meet client needs Integrating with early learning and education systems Anti trust

20 For more information: Full Cost and Quality Accountability Plan is posted More details on metrics at Also can contact me at: Smith